What are the next steps for investigating a 26-year-old female with symptoms of dizziness, migraines, syncope (loss of consciousness), and nausea, with normal tilt table test, normal electrocardiogram (EKG), normal laboratory results, and normal echocardiogram, and no past medical or surgical history?

From the Guidelines

For a 26-year-old female with dizziness, migraines, syncope, nausea, and normal initial workup, I recommend pursuing a neurological evaluation with a focus on vestibular disorders and autonomic dysfunction, as the most recent and highest quality study suggests that these conditions are often associated with similar symptoms 1. The next steps should include:

• A 24-48 hour Holter monitor to capture potential cardiac arrhythmias that might be missed on a standard EKG, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1
• Ambulatory blood pressure monitoring to detect orthostatic hypotension or POTS (Postural Orthostatic Tachycardia Syndrome), as defined by the 2017 ACC/AHA/HRS guideline 1
• A neurology referral is warranted for specialized testing including an EEG to rule out seizure disorders and vestibular function testing, as these conditions can present with similar symptoms 1
• Consider a 30-day event monitor if symptoms are less frequent, as recommended by the 2017 ACC/AHA/HRS guideline 1
• Detailed migraine assessment and management should be initiated, potentially starting with triptan medications like sumatriptan 50-100mg as needed for acute attacks, and possibly preventive therapy such as propranolol 20-40mg twice daily or topiramate 25-100mg daily if migraines are frequent, as suggested by the 2017 ACC/AHA/HRS guideline 1
• A sleep study may be valuable to identify sleep disorders that can contribute to these symptoms, as sleep disorders can exacerbate symptoms of autonomic dysfunction and vestibular disorders 1 These investigations are important because the constellation of symptoms suggests potential neurological or autonomic nervous system dysfunction that requires further specialized assessment despite normal initial testing, as emphasized by the 2017 ACC/AHA/HRS guideline 1.

From the Research

Next Steps for Investigation

Given the symptoms of dizziness, migraines, syncope, and nausea in a 26-year-old female with normal tilt table test, normal electrocardiogram (EKG), normal laboratory results, and normal echocardiogram, and no past medical or surgical history, the next steps for investigation could include:

• Considering neuroimaging to rule out any neurological causes, as suggested by 2
• Evaluating the patient for Chiari malformation type 1 (CM-1), as it can present with symptoms such as headache, vertigo, and transient sensory or motor symptoms, and has been associated with syncope 3, 2
• Conducting a thorough headache assessment, as migraine is a common symptom in patients with CM-1, and the prevalence of migraine in CM-1 patients is high 4
• Using risk stratification tools, such as the Canadian Syncope Risk Score, to determine the risk of adverse outcomes and inform decisions regarding further testing or hospital admission 5

Potential Diagnoses to Consider

• Chiari malformation type 1 (CM-1), as it can cause symptoms such as headache, vertigo, and syncope 3, 2
• Migraine, as it is a common symptom in patients with CM-1 and can be comorbid with secondary headache attributable to CM-1 4
• Other neurological or cardiac conditions that may cause syncope, such as cardiac syncope or reflex syncope, although the normal EKG and echocardiogram results make these less likely 5

Further Testing and Evaluation

• Neuroimaging, such as MRI, to evaluate for Chiari malformation or other neurological causes 2
• Headache assessment and characterization, according to the International Headache Society criteria, to diagnose migraine or other headache disorders 4
• Further cardiac evaluation, such as prolonged electrocardiographic monitoring or stress testing, if cardiac syncope is still suspected despite normal initial tests 5